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�MLIPt /IH WATER RESOURCES COOL BOARD <br /> FORM 'B': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEWPERMIi ❑7 RENEWAL PERMIT ,• <br /> /l.!/' S CHANGE OF IN 7 PERMAMENTLr <br /> ONE ITEM ❑2INTERIM PERMIT ❑A AMENDED PERMIT ❑ FORMATION ❑ CLDS TANK <br /> ❑6 TEMPORARY TANK CLOSURE El B TANK REMENED� <br /> / <br /> FACILITY/SITE NAME WHERE TANK IS IN6TAL1.Ep; "i - ., .-: '--^ �yp __ <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN— . N1cc Err ^ ARM TANK-VES❑ N <br /> ❑ <br /> A. OWNERS TANK IDM SO SPECIFY 10 <br /> B. MANUFACTURED 8Y <br /> C. YEAR INSTALLED <br /> D TANK CAPACITY IN GALLONS. P--a <br /> I I. TANK CONTENTS IF(A7),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. ~ <br /> A. ❑ I MOTOR VEHICLE FUEL ❑2 PETROLEUM co <br /> ❑ 3 CHEMICAL PRODUCT ❑1 OIL B /D C ❑ I UNLEADED ❑ 2 LEADED ❑3:^REBEL <br /> N <br /> 5 HAZARDOUS <br /> ❑ t PRppUCT ❑ .GA$AHO( ❑ S JET FUEL <br /> OD EMPTY ❑95 UNKNOWN ❑A;AWIAiION GAS <br /> ❑ ❑ ❑ 2 WASTE ❑ / METHANOL <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME Of ❑ 99 OTHER(DESCRIBE IN 60E WA REL OW) <br /> HAZARDOUS SUBSTANCE STORED 6 CA.S.6 /� <br /> .III. TANK CONSTRUCTION CAS M <br /> MARK ONE ITEM ONLY IN BOK A B C,AD /3 <br /> A TYPE OF t� ❑ 1 OOIBLE WALLED ❑3 WALE WALLED WITH ETTEROR LINEA <br /> SYSTEM I/ 02 SINGLE WALLED ❑4 SEONDAR/CONTAINMENT ❑%Lwi4owN <br /> ❑99 OTHER <br /> ❑E]E. <br /> I STEWRON 2 SA LESS STEEL 7 [:jT / ❑S CONCAEIE ❑6 POLYVW/L OILNOE 7 ALLWN I STFEI QAD w/FIBERGLAS$REINFORCED PLASTIC <br /> ❑ 9 BRONZE ❑ 10 GKYAN2H7 S FH 56 ❑6 LX%METHAI0 COMPATIBLE FRF <br /> ❑ �'�N ❑99 OTHER <br /> C INTERIOR ❑ 1 RAULMED E12 AM LNNG ❑3 EPUCY LNMNG ❑1 PHBMUC UNNG <br /> ❑9 GLASS"" ❑6 INNED ❑96 U I(JOW <br /> f� ❑ S LNMG MATERIAL.COWATEIF w m 100%LE7INNOL 1 YES ❑1O ❑99 OTHER <br /> D. CORK 1 POLYETHBEWAy ❑2TM CN A9RLALT <br /> PROTE ❑S GTFILOCRIDTECTION ❑9t NONE ❑3 VNIL WMP ❑I RBERGLLSS REINFORCED PLASTIC <br /> ❑95 LNK� ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE IF ABOVE GROUND U IF UNDERGROUND.BOTH IF APPLICABLE <br /> 7MATE.RIA7LA <br /> $ U I SUCTION A 11 2%E351MIE A U 3 GRAVITY <br /> A U 99OTHER <br /> U 1 SW WE WµyEp A U 2 DOUBLE WALLED A U 3 LINEDTRENCH A U %UNKNOWN A U >W OT/g1 <br /> U f $TEg/IRON A V 2 STAINLESS STEEL AU 7 POLrnNYL CLU 6 ALUMINUM A U 6 CONCRETE A U 7 STEEL CLAD W/FRP <br /> U 6 GALVANIZED STEEL A U %LMNNOWN A U 6100%METHANOL COMPATKE EAP <br /> A U BB OTHER{//LSV). AK ETECTION SYSTEM CIRCLE P FOR PRIAAAF'Y,OR S FOR SECONDARY.A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> L}.� I CHECK F ; 2 MlVEHTO RECONCKIATKM/ F 6 J VALxtSE WE113 F t .ELECTRONIC MONITOR E K 6 <br /> 7 6 6 PRECISION TESTMIG F • 7 PRESSURE TESTING ► 6 PI NONE P / %L ECTRO N GRA WATER MOWC",G WEDS <br /> 3 <br /> Y�V1. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE . . P9 DTHER <br /> 1 IMATED DATE LAST USED IMp/yR) <br /> l/ STMMTEG OUANTm OF <br /> X ANCE REMAINING IN AS TANK�ILIED WITH <br /> GALLOM6 1 ERT MATERMII DYES ❑ NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLJC,LNTg NAME(PRINTED 6 SIOHNTURq <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> JURNOtCTION r <br /> AGENCYTE <br /> FACILITY ID I TANK ID 6 <br /> j <br /> 28 LOCAL A61l1147F qE . <br /> ItJ 2 EG IIA61. <br /> AL DA FWMI DATA <br /> `::c a,.: _: :_: I:, ..- ,: .. - �� •-r.,,r -.,.N--�...�,-,., ....--,mow, <br />